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FOR OFFICE USE: � ¢ :Ix m <br /> -------------------- -- <br /> j APPLICATION FOR SANITATION PERMITPermit No. <br /> --------- _, ---•-••---- ...-- <br /> (Complete in Duplicate) _ - _... <br /> . . (�cli <br /> ------ This This Permit Expires 1 Year From Date Issued Date Issued __� <br /> Application is hereby made to the San Joaquin Local Health District for a permit t construct'and install the work herein described. , <br /> This application is made in compliance with County Ordinance No. 549. ® po7 phis <br /> I <br /> JOB ADDRESS AND LOCAfiION..i = dX-`3`I�° �C 7�K�/ ----- ------------------------------------- <br /> Owner's Name-----}� _�S.-'X _ -1 <br /> ---------------------------------------------------- - - ----- Phone-----4 -=-0 <br /> •------� ; <br /> Address------------------(- '`'e_ -----------------•---•-•-----•---------- ----•------------------------------------------------_-•-----_-_-------------------------------•--------4--•-•----- j <br /> Contractor's Name-----±------- ------------------------------------------------------ -------------------__--------------------- Phone..----------•--•--•-----••--------- t <br /> Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ T, <br /> Number of living units: __.Number of bedrooms ..3... Number of baths IA -Lot size -----3-----CL-e �_------------------- <br /> Wafter Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table :40- ft. <br /> Character of soil to adepth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ <br /> Previous Application Made: '(If yes,date-----------7........I No New Construction: Yes ❑ No 0 FHA/VA: Yes ❑ No,k <br /> TYPE'OF INSTALLATION AND SPECIFICATIONS: - <br /> 4 (No septic tank`;or'ces'spool permitted if public sewer is available within 200 feet.} + <br /> f , <br /> Septic Tank: Distance"from nearest well-----------------Distance from foundation--------------------Material-_-___._-.-.----___-_.-___--------.---..._--_.-. <br /> ❑ Noof compartmerits--------------------------Size---------------------------•---Liquid depth----------------------- --Capacity----------------------- <br /> Disposal Rel : Distance from nearest well.- J_f-___Distance from foundation---.--$00_`....Distance to nearest lot line--- <br /> lLiQ <br /> J Number of lines_____ ________ _______ __Length of each line-------- O'_--��____.Width of trench-__________ ,fC'`._____.._ <br /> �_�_ Depth of filter material _-_..__.Total length____________________ C�_ ___________ <br /> Type of filter material47-_ <br /> Seepage Pit Dis#once: <br /> 'to nearest well---/.9P0__"____Distance from foundation---_ ...___.Distance to nearest lot line_! -' p <br /> cfi Number of pits--------/_'-----------Lining imaterial =__4_a&Size: Diameter-----.- -----------Z- -------------- <br /> Cesspool: Distance from nearest well___---------------Distance from foundation--------------------Lining material----.-------------------------------- 0 <br />} d ' Size: Diameter------------------- --- ----------Depth--------_--------.---------------------------------Liquid Capacity------------------------------gals. G <br /> Privy:- Distancelfrom nearest well--_--:_.---`:._-- --------------------Distance.from nearest building--------------------------.------._____-- <br />{ Distancelto nearest lot line--------------j` ---------_ <br /> Remodeling and/or repairing [describe) �' _ `y --------- - --------- ----- <br /> 1 ----- <br /> r k <br /> ----------------------------------------------------------------------------------»._-____-__---__-__._-.-.-.------_--_---_._._----_-.-.._.----__--___-_---.--_-....______.____---_ <br /> ------------------------------------------------------------------•---- ---------------------------------•--•----------------------------------------------•-------------------------------------------------- <br /> I herehy certify that I have prepared this application and that the work will'be done in accordance with San Joaquin County i <br /> ordinances, State laws, and rules and regulations of the'San Joaquin Local Health District. <br /> 1 i,.- t <br /> (Signed)---------- *__a a tr•------------ -----------------k- ----------------(Owner and/or Contractor) `1 <br /> 1 ( p r � _ F � <br /> B (Title). ---- --------- <br /> Y• - =----------------------- ----------------- -_---- ----------- <br /> (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc., can .be placed on reverse side).. <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> } � - <br /> APPLICATION ACCEPTED;BY �- DATE <br /> t : _ <br /> REVIEWEDBY---- --------'--------------------------- ----------------------------------------- ------------=------------------------- DATE--------------------------------- ------------------------- <br /> BUILDINGPERMIT ISSUEDJ---------------------------------------------------- ------ ----- ----------------------- DATE--------------------- -------------- <br /> Alterations'and or re ommendations: ----------- --------------------------- -------------- ----------------•---------------------------------- ------•--------- ---------- <br /> -- ------------------------------------------------------ ----------------------------- ------------------------------------------------ <br /> ------------------------------------------------------------------------ --------_------------------------------------------------------------------------------------------------------' <br /> i f <br /> .............................'_--.--__...._-__--...__---____-...___-.----.....-.---_----__._-..-------__-.----.--._---_- _-.j--__-_.-...r___---..-.-_-------.-_.________.____.________..___________.___________________. <br /> `. 7 <br /> - - ---- -- D t _ .. - <br /> FINAL INSPECTION•BY:: I <br /> kl 1'+.,1. # <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazollon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> M <br /> Lodi,California anteca,California Tracy,California <br /> Stockton,California ... <br /> y <br /> E5 9 REVISED 8-59 3M <br />